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Does alternative medicine have alternative ethics?

Kimball Atwood has an interesting series of posts on the ethics of alternative medicine which I strongly encourage you to read.  He does a great job examining the ethical implications of certain alternative medicine practices, and has a terrific dialog with Peter Moran, a frequent commenter here.   At my other online locale, I make frequent forays into the morass of medical ethics, with an emphasis on specific clinical scenarios.  Today, though, I’d like to take a step back and examine the nature of medical ethics as they apply to so-called alternative medicine.

First, and perhaps most important, I am not an ethicist.  I do not have the depth of reading, the knowledge of terminology, or the specific education to lead a formal discussion on ethics.  What I am is a practicing internist, who must make ethical decisions on a daily basis. Most of these decisions are of necessity made “from the heart”, but it is not infrequent that I must evaluate a situation more formally and fall back on some of the ethical principles of my profession.

Ethics are not static.  They are not a divine gift bestowed on each of us as we don our white coats.  They are a living part of our specific cultures, and of the profession we serve.  Some of the modern principles of medical ethics are newer than others.  Beneficence, non-maleficence, and confidentiality are ancient principles of medical ethics, which continue to be relevant today.  Patient autonomy is a more recent value, reflecting a shift in how society views the relationship between patient and physician.  These ethics must be mutable, as the profession itself is ever-changing.  Despite this fluidity, there is an identifiable line of “doctor-hood” that has existed for at least the last century, and the members of this guild have always tried to adhere to some type of code of behavior.

Alternative medicine poses real challenges to the principle of medical ethics.  First, we’ll discuss who, in fact, is bound by these principles, then the way in which alternative medicine is or is not compatible with medical ethics.

Who is a physician?

The identity of “physician” in North America is generally understood as referring to someone who has completed medical school, other requisite training, and is practicing medicine.  In other cultures, there are other types of healers (such as curanderos) and how our ethics may apply to them is unclear.

What about people who present themselves as doctors, but do not practice the science-based medicine that we teach and practice?  They may have an M.D. or D.O. degree, they may even be board-certified, but if they are practicing outside of the standard of care, are they still bound by the same system of ethics as their more traditional colleagues?

Absolutely.  Anyone who presents themselves as a doctor must behave in a way concordant with medical ethics.  A patient seeking help should expect the same ethical treatment from all practitioners.  No doctor is exempt from our ethical principles.

What about a doctor who believes in the implausible medical claims that they practice?  Since they believe that they are helping the patient, aren’t they behaving ethically?

If intention were the only principle of medical ethics, well, sure.  But good intentions do not excuse incompetence, and one of our responsibilities as physicians is to strive for excellence in our knowledge and practice.  This means maintaining our science-based education.

What about non-physicians who offer quasi-medical services? Professionals such as nurse practitioners have their own codes of ethics, but often enough non-professionals such as homeopaths, acupuncturists, and others present themselves as healers.  Patients have a responsibility to educate themselves and protect themselves from harm, but people who are suffering are vulnerable, and non-professional healers take advantage of this vulnerability.  While they are not bound by the same medical ethics that I am, they are bound by the same ethical principles that all of us are as members of a larger society.  As a society, we generally frown upon folks pretending to be experts and futzing around with people’s health and hopes.  We only tolerate “alternative healers” because their deceptions extend beyond their victims—we sometimes believe they are doing good, even if they are not.

Alternative medicine is prima facie unethical

To the extent that alternative practitioners are bound by medical ethics, alternative medicine is unethical. It violates most of the commonly agreed-upon precepts of our profession.  Medicine is based on the humane application of science-based practices.  Standards of care are based on either what has been shown to work, or when insufficient data is available, what we as a profession agree is likely to work.  There are written resources that any doctor can look up in minutes.  Altmed practitioners don’t “slip” away from real medicine, they intentionally turn away from it, sometimes with good intentions, sometimes not. So-called alternative medicine practices are ethical failures on many levels.  As to the principle of beneficence, the most benefit they may offer is emotional comfort, something real medicine could just as easily offer.  When it comes to non-maleficence, it fails miserably, in that it often deprives patients of real treatments, or subjects them to ineffective ones.

When it comes to patient autonomy and truthfulness, however, it really hits a wall.  For a patient to exercise autonomy, they must be as informed as possible.  If an altmed practitioner were to truthfully inform patients that the wares they are peddling have never been shown to be useful, are shunned by real doctors, and may in fact harm, patients would knock each other down to get out the door.  But they don’t.  When they do give lip service to the unproven nature of their practices, it is always with a wink and a spiteful nod to those silly non-believers at the hospital.

Even the most heartfelt modern shaman is an unethical sham.  Alternative medicine, that is medicine that is outside the embrace of science-based practice, is inherently unethical, and it’s time to call it what it is—a blight on our profession, and so far as we tolerate it, a blight on us all.

Ethics resources

The American Medical Association’s Principles of Medical Ethics

The Charter on Medical Professionalism

Ethics at University of California San Francisco

Posted in: Medical Ethics, Science and Medicine

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22 thoughts on “Does alternative medicine have alternative ethics?

  1. skeptyk says:

    Thanks for this. I have found some people think it is ethical for one to practice quackery as long as the person really believes in their practices, that if fraud is not intended then it is an “honest mistake”. It may be unfortunate, even harmful, but it was not malicious, therefore not unethical, goes that argument. Outsized relavitism, methinks.

    The “kindly quack” defense, as I may call it, is perhaps a way for folks to deal with the cognitive dissonance they feel when faced with a nice person, a well-meaning person, who is earnestly using nonsense medicine.

    BTW, I wrote about alernative ethics a bit ago: http://www.metaphoria.org/ac4t0704.html

    Medical ethics has transformed the profession during my lifetime. Since much of SCAM proudly proclaims its antiquity, then it is fitting to notice old-fashioned medical ethics are common to SCAM, including paternalism, lack of informed consent, abuse of power, experimental bias and sexism.

    Those who (should) know better are the main promoters of “integrative medicine”. Scientifically trained, and by virtue of education and experience, doctors, nurses and dentists have significant authority and real power over patients. Appeaser-integrators allow SCAM to get its grubby foot in the door via such “benign” practices as homeopathy and therapeutic touch, selling them with the “won’t hurt, might help, people like it” hook.

    Homeopathy and Therapeutic Touch (TT) are a waste of both the nurse’s and the patient’s time. The int’grate pleads that time itself is the reason TT and Homoeo are good. The therapeutic relationship is important to compliance and to placebo, so the extra time it takes to provide pretend medicine is justified as developing the relationship so the patient will be more likely to comply with the (real) medicine we recommend.

    Honestly, this is the argument I got from someone who could not look me in the eye and say either of those was other than placebo in drag. Yecch. To assume we must fool our patients with ritual magic in order to gain their trust so they will follow a reality-based treatment plan is to dishonor both our patients and our professions.

    Since both TT and homeopathy are faith-based (vs. reality-based) practices, it can be argued that they are needlessly intrusive of the patient’s mental and physical space, as well as denigrating the patient’s autonomy and dignity. How insidiously intimidating for a patient – already made vulnerable by disease – to be coerced into CAM rituals by the very people who are supposed to be the patient’s advocates.

  2. Bravo!

    Well said.

    I agree completely.

    Interesting how your compatriots continue to justify the appearance of those “unethical” ads on the blog’s sidebar.

  3. Peter Lipson says:

    I can’t say that I agree with “justify”. There is no ethical prohibition against these ads. In fact, I’d say that having them here is more laughable than unethical. We are making a buck off of the advertisers while simultaneously tearing apart their offerings. Ironic, yes; unethical, no.

  4. Fifi says:

    I hardly see how google ads can be considered unethical in the same way ads in a magazine can be considered likely to influence editorial content. Google ads aren’t random but they googleplex is not as evolved as many people seem to think (Adsense ads are chosen by keywords, which is why so often what’s advertised rather amusingly contradicts what’s being written about on the site they show up on). Magazines and newspapers choose which advertisements go in so ARE making a conscious choice and can potentially be influenced by their advertisers.

    Plus, apart from anything else, this blog actually makes less money from google ads for CAM kind of stuff since they’re not the kind of ads that readers here are likely to click through to, which is how you make money through Adsense.

  5. adiemusfree says:

    As Prof Dennis Dutton said, probably thinking of Angell & Kassirer, There is no ‘alternative’ healthcare: simply healthcare that works, and healthcare that doesn’t. He once said in a lecture I listened to ‘If there is such a thing as alternative evidence, then please excuse me from flying in an aeroplane built on alternative physics, I’d rather know it can actually fly’.

    Knowingly peddling health care that has no evidence base is unethical. I’m not so sure of those who genuinely believe that what they’re doing ‘works’. Which is why I’m making sure the people I see for my health are from ‘conventional’ health care, and I will provide my patients with ‘conventional’ health care.
    It’s really about being honest.

    Angell M, Kassirer J. Alternative Medicine — The risks of untested and unregulated remedies. New England Journal of Medicine 339:839-841, 1998.

    There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.

  6. pmoran says:

    There is only one valid reason for preferring conventional methods over “alternative” methods and that is that they work better,. The ethical argument itself depends upon that being generally true.

    But alt methods are very often tried under circumstances where there is no entirely satisfactory conventional method and where the users are quite happy with any limited benefits they may derive from them. This fits in with an evolving understanding of the non-specific influences of medical attentions on patient well-being and ability to cope with illness. It is not yet clear whether some form of symbolic or pretend medicine is necessary for full effect.. The point is that alternative medical activity is protean, and not all of it can be squeezed into the ethical and scientific models that we habitually work from.

    The ethical argument also cannot be put without us looking a little pompous and holier-than-thou, inviting even those of moderate views to take us down a peg or two. They will point out that we are nowhere near supplying the good, safe, comprehensive medical care that the public expects of us. We can do a lot of harm to people even by doing what we are sure is right — that IS right most of the time. In proportion to this the harm done by “alternative” medicine is close to trivial, as some delight in saying at every opportunity. And doctors and drug companies can be made to look like a bunch of crooks just as easily as can alternative practitioners, by selecting out the bad eggs. Don’t bother arguing against these points — I have made all those arguments myself — I am telling you about common perceptions.

    Patient autonomy is also completely inconsistent with the view that the only ethical medical practices are the ones that we doctors subscribe to as a group and can persuade patients to accept. That’s OK, many ethical judgments entail choosing which of opposing rights and obligations we wish to emphasize. I simply ask what weight the masses are going to give to opinion that just happens to suit doctors’ aspirations and pocketbooks and that also serves as a suspiciously convenient all-purpose demonizer of “alternative” medicine?

    Has no one else noticed that a body of research points to the possibility (only that, but suggestive at this stage) that commonly used pharmaceuticals used under the conditions of normal medical practice or as DIY medicine will be no more helpful but more risky than some of the pretend medicines of CAM? There is actually nothing in the available evidence to stop a placebo medicine “working” better than an active pharmaceutical, if supplied under exceptionally favorable conditions. In fact some drugs are accepted for marketing with benefits that scarcely outnumber their side effects and that are less than those commonly demonstrated from placebo.

    Others are thinking along these lines, which is perhaps why we are now seeing more uncontrolled clinical studies of CAM, designed to assess real-world outcomes and cost-effectiveness rather than answer mechanistic questions. We love to tear such studies to shreds, without noticing that they are asking questions other than those we wish to impose on them. I predict that most will NOT show cost-effectiveness for CAM methods, but some may, and many will probably perform as well as bog-standard conventional care. We should be prepared for that possibility.

    This is NOT an argument for whole-sale endorsement of alternative methods. I am playing devil’s advocate because I strongly feel that if we wish to be influential and preach effectively beyond the SBM choir we need more temperate and precisely targeted arguments, ones better suited to an already well-established rhetorical landscape and to what present evidence allows.

  7. daijiyobu says:

    Dr. L. wrote:

    “alternative medicine is prima facie unethical. To the extent that alternative practitioners are bound by medical ethics, alternative medicine is unethical. It violates most of the commonly agreed-upon precepts of our profession.”

    I disagree with the “prima facie” label, though I completely agree with your evaluation of the actual situation of alt. med. in terms of the established ethics of the medical profession, and I’d add ‘the professions in general.’

    I don’t think that to the AVERAGE person alt. med. is upon casual glance obviously unethical. You have people posing in white coats with stethoscopes around their necks in various media calling themselves physicians, regionally accredited colleges and universities, state and federal so-called ‘regulatory bodies,’ etc. claiming that the hugely nonscientific is in fact scientific.

    I’ve termed the whole alt.med. / CAM lot, and particularly naturopathy, “unethical sectarian pseudoscience:”

    for instance, and this is only one example, the Southwest College of Naturopathic Medicine claims naturopathy is science (http://scnm.edu/forms/scnm_naturopathic_medicine.pdf ) while coding their vitalistic core belief and not revealing its science-ejected nature.

    There’s nothing prima facie in that strategy — it is a complex deception — and it is quite unethical in so many ways — once you delve: from a position of falsehood and deception, naturopathy claims to be able to meet the central role of a professional — fiduciary duty.

    Absurd.

    Perhaps we’re seeing a parallel: years of ‘fiscal deregulation’ leading to our current global financial emergency, and years of ‘epistemic deregulation’ leading to the sectarian-absurd being falsely claimed as ‘objectively medically actual.’

    OBNE, anyone?!?!?! (see http://www.oregon.gov/OBNE/Aboutnaturopathy.shtml ).

    They are the winners in terms of misrepresentation: when the ‘HUGELY science-ejected for decades’ is claimed several decades later ‘to be able to robustly survive scientific scrutiny’ — with a .gov web extension [and you can find all this in college guides, galore, too] — well, lots of people WILL suffer harm due to misguidance via unethical sectarian pseudoscience.

    -r.c.

  8. Peter Lipson says:

    I suppose you’re right. Perhaps what I mean is that once the ethical situation is evaluated, it becomes immediately apparent that it is unethical.

    And Moran’s analysis is as always appreciated, although I must respectfully disagree with a number of of his points, specifically the implication that CAM should be judged by different standards than “real” medicine (although I realize the point is more subtle than that).

  9. Fifi says:

    “To assume we must fool our patients with ritual magic in order to gain their trust so they will follow a reality-based treatment plan is to dishonor both our patients and our professions.”

    Is being attentive and caring “ritual magic” though? Is listening and kindness “woo”? (Certainly those with a more stoic approach to pain and suffering – and health in general – can have a tendency to think so, whether they’re doctors or any other profession.) Is treating the patient and not just the symptoms “woo”? How many contemporary doctors really do treat the whole person and not the symptoms? How many really even have the training to do so?

    (Clearly in the US, at least, there’s a tendency to medicate symptoms rather than look for underlying causes and contexts – this is partly the results of a system that works according to private insurance so treats according to what is allowed by a non-medical organization, a tendency to take a pharmaceutical approach to both illness and general malaise which is connected to doing medicine by the rules of private insurance, and a bit of historical debris left over from the days when doctors expected to be treated like gods.) Unfortunately, some people DO go into medicine for the status and money, not because they actually like or care about people (which can be fine if you’re a researcher or scientist but a rather big handicap if one is a practicing doctor, whether one is a GP or a specialist).

    All most doctors need to do is not LOSE their patient’s trust. One doesn’t even have to lie to a patient about a treatment being a placebo. Practical medicine is about treating people not just symptoms and dispensing medications (that’s what pharmacists do), if being kind or caring seems like “woo” – or somehow irrational and not part of being a doctor – then I’ve got to wonder what that individual is doing practicing medicine (apart from making payments on a BMW).

  10. skeptyk says:

    @Fifi:

    “Is being attentive and caring “ritual magic” though? Is listening and kindness “woo”?”

    Of course not. I was speaking about the extra trappings of homeopathy and TT. Certainly kindness and listening are part of medicine and nursing, as well as of TT and Homoeo. Goodness need not be dressed in CAM clothing.

    Sadly, folks use the kindness/attentiveness component to validate CAM, as if caring is CAM’s property or as if CAMmers are better at it than conventional medicine. I would like to see a fair assessment of the assumption that CAM cares more/better.

  11. Peter Lipson says:

    Clearly in the US, at least, there’s a tendency to medicate symptoms rather than look for underlying causes and contexts

    I don’t buy it. This is the frequent cry of the Nulls and the Mercolas, but I think it’s wrong, at least from my perspective as a practicing internist. In fact, it doesn’t even resemble the truth. Actually, as I think about it more, it’s not even wrong.

  12. skeptyk says:

    Hmm. Why do you say that “Clearly in the US, at least, there’s a tendency to medicate symptoms rather than look for underlying causes and contexts …”

    I read your post, Fifi, which explains why you think such halfassed medicine may be practiced, but I do not know why you think that this particular halfassedness IS common.

    Often it takes little time or testing to know what ails someone, i.e., “the underlying causes and contexts”, and thereafter, yes, treatment of symptoms may be “all” that’s left to do for the patient. That is not a failure of medicine, it is rather terrific.

    (Kindness and manners may influence a patient to be more compliant with one’s treatment plan, but that goes for SBM and CAM alike.)

  13. Fifi says:

    skeptyk – Sadly CAM practitioners seem to have cornered the market, so to speak, on compassion (or, more accurately, on appearing to be compassionate or the providers of compassionate care). Doctors are just people so they come in all flavors (and patients arejust people too so they come in some highly irritating flavors like annoying Aunt Ruth or whoever gets under our skin ;-)). Of course, not all people’s jobs involve caring for others. We tend to think of doctors as healers but a doctor’s job isn’t just to heal – because that’s not always possible since some things are incurable – it’s to care for the person. Many doctors do a fantastic job of this, unfortunately there are others who don’t.

    As difficult as it is to see one’s own culture from inside that culture, medicine also has its own rituals that attain their power from being rituals (these may well differ according to where and who is practicing medicine). Additionally, each of us has our own cultural relationship with illness and pain that we learn from our family and the larger social context which we were raised in.

    I’m not validating or intending to validate CAM, just pointing out why some people feel they’re getting more effective treatment from a CAM practitioner. People go to the doctor to “feel” better, for most people “feeling better” has an emotional and psychological component, it’s not just physiological. Suffering and pain cannot be measured objectively, they can only be understood within the context of the particular patient.

    Neither CAM nor medicine care per se (how can they?) but there are caring practitioners in both (being caring doesn’t actually mean one is automatically effective!). That said, some CAM modalities give the IMPRESSION of being more caring since the entire process really rests on listening, reassuring and sometimes even a hug or gentle caress….a bit of mothering. Not surprisingly, mothering makes many people feel a bit better (emotionally) when they’re feeling sick and vulnerable. So it seems that CAM practitioners are sometimes better responding to patient’s emotional, psychological and social/cultural needed which leaves the patient feeling satisfied and “feeling better”. I’d suggest that rather than “validating CAM” what some people are doing is explaining what purpose CAM serves for themselves or others (though I’d suggest that therapy with someone qualified to be a psychotherapist would be more useful than getting hugs from someone who’s unclear on physical medicine and highly likely to be very unclear on transference, counter transference and ethical therapeutic relationships). So, I’m no supporter of CAM, just someone who recognizes that if we listen to people they often tell us what we’re trying to find out. It seems pretty clear to me that there are a couple of things people feel they get from CAM practitioners that they don’t feel they get from doctors, and these used to be the domain of medicine but no longer are in the public mind.

  14. Fifi says:

    Of course treating symptoms is terrific but not if it’s a means to ignore or avoid the cause of the symptoms.

    It seems to me that the US insurance-driven medical system limits doctors and defines treatment for many people, creating a context where fast and cheap treatment of symptoms is favored over longer, more expensive treatments. Public medicine has its problems too that make it more difficult for doctors to provide compassionate care and are driving people towards CAM too.

  15. pmoran says:

    “And Moran’s analysis is as always appreciated, although I must respectfully disagree with a number of of his points, specifically the implication that CAM should be judged by different standards than “real” medicine (although I realize the point is more subtle than that).”

    Yes, there are subtleties to my position that I clearly lack the verbal skills to convey. Trying again, in no way am I suggesting that CAM methods be judged by different standards to conventional. I am suggesting that a perhaps more clear-sighted cost/risk/benefit analysis should be applied to both.

    A dubious element in the typical skeptical position is the assumption (usually unspoken but clearly in the background) that alternative medicine is of no value to any person under any circumstances. Being able to feed zero benefits into the equations always provides the desired answer — and , of course, the right answer in relation to a great many medical questions.

    But the complexities of medical practice at its fringes almost guarantee that such an analysis will give some surprising results, and if that means that dubious methods sometimes perform as well as or better in risk benefit terms than conventional methods, we should be grown-up enough to accept that, in the interests of not doing more harm than good to some patients. We should not let our “this has no right to work” impulses overwhelm our responsibility for the welfare of the public.

    The importance of this is not merely the fact that it may well be closer to the truth of things, allowing for some of the mysteries that still apply to how folk respond to medical attentions. It providea a rational approach for professional and public policy regarding “alternatives” that BOTH SIDES should be able to accept. For one thing, it gets around that “it can’t work/ yes, it does” impasse.

    Among other benefits it could have some effect on the kind of research that is done. Money might not be wasted on so much research directed at vindicating alt.med theory, or producing outcomes that placebo theory can predict. Money could be directed more at weaknesses in current medical care. An example might be “can good chiropractic care get back pain patients back to work quicker” (we already have evidence that it doesn’t but this is an example of worthwhile research if there are the funds for it). “Can acupuncture reduce the need for drugs for cancer pain” might be another worthwhile project so long as the study can be designed so as to avoid any dampening effect of the controlled trial format on “placebo” responsiveness (actually responsiveness to the whole package of care), and only objective end-points are sought..

  16. The Blind Watchmaker says:

    Instead of “CAM”, I prefer Mark Crislip’s term, “SCAM” (Supplements, Complimentary and Alternative Medicine). This term seems more appropriate.

    As Peter pointed out above regarding the myth that traditional doctors just tend to treat symptoms, rather than looking for root causes,…. this is absurd. It is naive. If this was not actually tossed around so much, it would be like a straw-man as it is so easy to knock down.

    Most people with hypertension, diabetes and hyperlipidemia have NO symptoms. We are very aggressive about treating these and many other things. We do this because we have learned the causes of many diseases (or at least the risk factors).

    When someone comes in with chest pain, we do not just hand him or her a pain medicine and send them off. The cause of the symptom is hunted for aggressively so that we may treat it. It would be easy to eliminate symptoms, but people would die.

    When someone comes in with back pain, the doctor determines the likely cause and decides on the appropriate therapy based on the published evidence. Sometimes, this does involve just treating the symptoms because the underlying cause may be self limited.

    Many times, the underlying “cause” as determined by the SCAM practitioner involves some implausible concept such as “blocked chi” or unbalanced humors.

  17. AllYourBase says:

    “if being kind or caring seems like “woo” – or somehow irrational and not part of being a doctor – then I’ve got to wonder what that individual is doing practicing medicine (apart from making payments on a BMW)”

    Yeah, ya got to wonder. Of course, “kind and caring” certainly isn’t all there is to it, and some doctors seem to go way too far with that. Read about Dr John A Beall, Jr and his “ethics”. This is not to say that because doctors sometimes take disgusting liberties with their patients, that all doctors are scumbags. It’s a reminder of the high standards we should have for all doctors, and the seriousness of the trust we place in them.

    I don’t think it’s appropriate for a doctor to suggest CAM unless he honestly believes it’s going to do some good. And if he honestly thinks CAM is going to do some good, he’s probably a sloppy doctor.

  18. Fifi says:

    TheBlindWatchmaker – I certainly don’t think all doctors merely treat symptoms or it’s universal in healthcare (both my parents are doctors), my point was that in the US there’s systemic pressure for doctors to treat symptoms (coming from the intrusion of business concerns about shareholder profits and the need to always increase profit – not for doctors but for insurers). There are all kinds of reasons why private insurers are less interested in preventative health than public health systems are (the main one being that it seems to be relatively easy to drop people who become very ill). And, yes, some private health insurance does cover quite a lot of tests but then it also usually covers SCAM and SCAM tests too so that’s hardly an indication of putting the patient before profit or the patient/doctor relationship before profit.

    I know it can be difficult to discuss these issues without them getting personal. After all, I too have a bias because when people insult doctors they’re insulting my mom! My point isn’t to insult doctors, it’s to discuss the value of the therapeutic relationship and trust in the patient/doctor relationship. I also have a particular perspective or bias regarding these things because I worked briefly in a pain clinic so the relationship between the patient and the team was considered an aspect of the treatment. It’s also an area of medicine where subjectivity and the psychosocial aspects of illness are considered highly relevant. Clearly the practice of medicine is quite different depending on whether one is a GP or specialist, and where one practices.

    Anyway, I do tend to lean towards Dr Moran’s position since I believe it’s ultimately about treating the patient and relieving suffering the best that one can (my apologies to Dr Moran for any discomfort this association may cause!). If wearing purple socks consistently meant people suffered less pain but we couldn’t figure out why, it would be worth figuring out if it was the purple socks. We already use various treatments that we don’t understand the underlying mechanisms for or that are unproven (medical history is littered with discarded treatments) and we also use placebo treatments. That doesn’t mean I believe we should accept SCAM as medicine, however I often see people dismissing all kinds of legitimate parts of medicine along with it – the therapeutic relationship, nutrition, preventative medicine, etc. This seems rather reactionary (though I understand why many doctors have knee jerk reactions against SCAM) and not in the best interests of doctors, medicine in general or patients.

  19. Fifi says:

    It is not, of course, kind or caring to sexually or physically abuse a patient or to use one’s position of authority to do so. I do find it odd that anyone would automatically think of sexual misconduct and breach of trust when discussing creating a therapeutic relationship that is caring and generates trust. So, in your mind, are the only options relationship with no trust or an abuse of trust by the doctor?

  20. MedsVsTherapy says:

    Nice post. Hopefully, medicine could one day progress even farther to be evidence-based, versus science-based. There are many putative remedies that are solidly in the heart of what you are calling “science-based medicine,” but that are ineffective, and potentially are harmful. this includes: HRT (for several years, the best-selling pharmaceutical, until evidence revealed that HRT actually causes, not protects from, heart disease); arthroscopic intervention for knee pain; vitamins for just about whatever you might want to take them for (with the exclusion of folate for prenatal spine health); antioxidants; antidepressants; cox2 inhibitors; routine episiotomy; about half of the cardiac stents that are done; etc.
    For each, there is some actual physiological, “science-based” mechanism, such as the antioxidants swooshing away the harmful free radicals, or HRT promoting smooth blood vessel tone. Antioxindants do have some effect on free radicals, and estrogen does have an effect upon various skin tissues. The immediate cause-effect is there. But then, docs are willing to accept the extrapolation to the whole human body, disease, etc. Sure, this is an inference with some scientific basis. But until you have evidence that some preventive or treatment effort actually achieves what it is supposed to achieve, you are falling short of EBM, although you may be practicing SBM. Because you were taught that way, or because clinical guidleines suggest is no defense, whether in traditional SBM or SCAM.

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